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VOTE HAM fl1E� M COUNT <br /> • <br /> MININIIG RECLAMATION PERMIT APPLICATION <br /> CRS 34-32-112 (10)(a) (Filing Only) <br /> Applicant Name 11"I'LIL— Date Received 7- <br /> Permit # <br /> Date of the Hearing <br /> Contact Name and Phone #: <br /> Name: )�` 4yc� S Phone #_ -,>Al <br /> please print <br /> Please check which box applies to your permit: <br /> I wish to be contacted 30 days after the hearing to pickup the application <br /> ❑ I do not wish to pickup the application 30 days after the hearing and I hereby give <br /> the Clerk's Office permission to destroy this filing <br /> Signature <br /> Accepting c-� Date of Filing 3 1 '9 ��i <br /> :wnont C'nw tv eta& and geed" <br /> 615 Af acan Que Suite 1021103 <br /> eairon eit*,eV 81212 (719)-276-7332 �ftwW gwntffam@fwnont oxmn <br />